Erin's Spot

Recently a friend brought an article to my attention regarding mobility exercises. The article addressed how often times people utilize mobility exercises to correct or improve movement patterns that are more likely the result of motor control issues, rather than limited mobility. So, how do you know if your movement issue is a mobility problem vs. a motor control problem? One of the easiest ways is to remove one important factor… gravity!For example, if you are having trouble performing a squat in the usual upright standing position, lye on your back and try to bring your knees to your chest. If you are capable of bending your knees and hips enough to get your knees to your chest, then you have the proper mobility to perform a squat, however you may not possess the proper motor control to execute the squat. Mobility is the body’s physical capability to move through a full range of motion, whereas motor control is the body’s capability to take sensory input from the environment and execute the proper muscle coordination in response.The best way to improve motor control is with PNF. Proprioceptive Neuromuscular Facilitation (PNF) is the body’s understanding of its position in space. Dynamic exercises work best to improve PNF because of increased sensory input from the environment. The more input the body receives, the more information it has to work with and respond to thus improving balance, coordination, and motor control!Another somewhat confusing issue in the fitness and rehab fields is stability training vs. strength training. While it may seem like improving one would inherently improve the other, this is not the case. The larger muscle groups in our bodies such as the pecs, quads, and hamstrings are the ones we utilize all day every day to sit, stand, walk, lift, push, and pull, but it is the smaller stabilizing muscles in our neck, back, and extremities that we don’t think about that allow us to react to our environment, remain in proper alignment, and prevent injuries.Many people think they are performing stabilization exercises, when in reality they are just strength training the large, primary muscle groups. The smaller, stabilizing muscles in our bodies are reflexive, and rely on motor control rather than strength to function properly. Therefore, the best way to improve stabilization is to improve motor control, and as we just discussed, the best way to do that is with PNF. It is also important to remember that whether you are training for strength or stabilization, especially when trying to correct a movement issue. First you have to deactivate the compensatory muscle(s) before you can properly activate the appropriate muscle(s).In a nutshell, you have to have mobility before you can do anything else. Without the ability to move, it won’t matter how good your motor control or strength is! Once you can move, you then need motor control to be able to properly respond to the environment around you. Once you can move and respond, then you can work on stabilization to be able to respond more efficiently. Lastly and only once the first three factors are well established, should you add load to your body to improve strength. At a recent seminar Gray Cook said, “Stability is the body’s ability to maintain alignment with integrity under load.” The most important word in that sentence is integrity. If you cannot maintain integrity under a weighted load, then you have no business strength training!!Step 1 – MobilityStep 2- Motor ControlStep 3 – StabilityStep 4 – StrengthIf you fail at step 4, go back to step 3… If you fail at step 3, go back to step 2. If you try to push your body when it’s not ready, you will fail and most likely injure yourself in the process….and then you have to start at step 1!!

Today’s post was inspired by one of my most difficult patients… my father! While at work my father felt a strain in his right shoulder while lifting a heavy piece of equipment and after letting the pain nag him and hinder his movement for over a week, he FINALLY asked for my help.The shoulder is probably one of the most complex joints in the entire human body… so let’s talk about some of its components and then we can have a better understanding of how to fix them.The shoulder complex is comprised of the 3 joints; the sternoclavicular joint which connects the clavicle (collarbone) to the sternum (breastbone), the acromioclavicular joint which connects the acromion process of the scapula (shoulder blade) to the clavicle, and the glenohumeral joint which connects the glenoid fossa of the scapula to the head of the humerus (upper arm.) The glenohumeral joint is the ball and socket joint that most people think of when discussing the shoulder. Because the glenoid fossa (socket of the joint) is smaller than the humeral head (ball of the joint) the shoulder has a very high degree of mobility, but less stability than other ball and socket joints, such as the hip. Luckily the shoulder is also comprised of numerous muscles and ligaments to help stabilize the humeral head, preventing it from dislocating from the socket.One of the most important muscle groups in the shoulder is the rotator cuff, which consists of the supraspinatus, infraspinatus, teres minor, and subscapularis muscles. Theses muscles work as a unit to ensure proper movement of the scapula, which then allows the head of humerus to remain in the socket.Because the rotator cuff muscles are necessary for so many of the activities we perform on a daily basis, the tendency for overuse injuries to this part of the shoulder is very common. Therefore, it is vital that we keep these muscles strong enough to withstand the repetitive motions we put them through every day. These are some simple stretches and exercises you can perform to maintain your rotator cuff:*Remember to always begin with non-weight bearing exercises and slowly progress in resistance, especially when first starting an exercise program or recovering from an injury!

I-Y-T-W-O Exercise: Begin standing or lying on your stomach, stretch both arms straight overhead to form an I, then slowly widen your arms into a Y shape, then straight out to your side to form a T. If you can perform these 3 movements without pain then you can progress to bending your elbows in towards your ribs to form a W, and then lower your hands to your lower back with your palms facing out to form an O. Do 3 sets, holding each position for 3-5 seconds.

Stick Stretch: Begin lying on your back holding a small dowel or stick with both arms perpendicular to your body. Slowly extend your arms overhead keeping both arms straight, hold the stretch for 3-5 seconds, and then return to the starting position. Perform 3 sets of 5 reps.

The Empty Can Exercise: This exercise specifically targets the supraspinatus muscles, which is the most commonly injured muscle in the rotator cuff. Begin standing and extend the arm of the affected shoulder at a slight diagonal, with your thumb pointing towards the floor, as if you are dumping out a can of soda. When this movement can be performed repeatedly without pain, then you can add a free weight or resistance band to improve muscle strength. Perform 3 sets of 10 reps.

Wall Pushup: This exercise is performed exactly as it sounds. Begin by standing arms-length away from the wall and perform 3 sets of 10 pushups. To increase resistance, step further away from the wall to increase the amount of body weight being placed on the arms and shoulders. Progress to performing pushups on an incline bench, and then eventually the floor.

Planks: My favorite exercise of all, planks are ideal for improving shoulder stabilization. However, planks should ONLY be performed when there is absolutely NO pain when performing any of the previous exercises. If you begin to experience pain in the plank position, return to the wall pushup until your shoulders are strong enough to support your entire body weight.

Another common shoulder injury is an AC joint tear, often referred to as a separated shoulder. The acriomoclavicular joint is connected by the acromioclavicular ligament, which can tear due to a fall or impact injury, which is common in many contact sports. The severity of the injury is graded 1-3.A Grade I injury involves a slight tear in the AC ligament, but the joint is still in tack. This type of injury is the most common and resolves on its own with a short period of limited activity.A Grade II injury means there is a complete tear in the AC ligament, creating a dislocation between the clavicle and acromion process of the scapula.A Grade III is a true separated shoulder. With this type of injury, not only is there a complete tear in the AC ligament, but there is a complete tear in the coracoclavicular ligament and joint capsule as well. A true separated shoulder requires surgical intervention to repair the torn ligaments.The first priority when recovering from surgery is to regain range of motion. This is often a slow and tedious process, but a necessary one in order to restore proper function to the shoulder. Range of motion exercises should include:

Wall Climbs: Standing facing the wall, slowly walk your fingers up the wall and then back down. Perform 10 reps and then stand perpendicular to the wall and repeat 10 reps with your arm to your side.

Internal/External Rotation: These can be performed sitting, standing, or lying down. When recovering from an AC tear I would recommend performing this exercise lying down without any resistance, and slowly progress to sitting using a light free weight, then standing with increased weight. To begin, lye on your back with your elbows bent to 90 degrees so that your fingers are pointing to the ceiling. Slowly let your hands fall back towards your head so that the back of your hands are on the floor, return to the starting position, then let your hands fall towards your hips so that your palms are on the floor. Perform 5-7 reps, holding each position for 10-15 seconds.

Once full range of motion is restored without pain, the patient can return to normal activity.Keep in mind that the shoulder is a hyper-mobile joint that requires the proper balance of mobility and stability to function properly and reduce the rate in injury.Everything is connected, and a problem in one joint can often lead to problems in adjacent joints if left untreated. Listen to your body… if something feels wrong, then it probably is!

So I just returned from a 3-day functional training summit and have loads of information to share with all of you, but I wanted to take the time now to piggy-back on Dan’s recent post regarding form and function.Two of the presenters that had a profound influence on me at the training summit were Gray Cook and Greg Rose. Gray Cook is a physical therapist who helped create the Functional Movement Screen, an assessment tool used by athletic trainers and coaches prior to training to screen for irregular movement patterns that could potentially cause injury.The full assessment includes the deep squat, hurdle step, in-line lunge, shoulder mobility, straight leg raise, trunk stability push-up, and rotational stability. Each exercise is scored from 0-3, and considered dysfunctional (or irregular) if receiving a score less than 3. If the athlete receives a score of 0, this indicates that movement is not only incorrect, but causes pain. In these cases the athlete is often referred out to a sports medicine clinician who will then assess the athlete with a Selective Functional Movement Assessment to pinpoint the cause of pain.This is where Greg Rose, a chiropractor and director of the Titleist Performance Institute, offers simple easy to follow guidelines to diagnose and treat altered movement patterns that cause pain.1.) Distinguish between thesourceof pain and thecauseof pain. Our skeletal system is an alternating pattern of mobile joints and stable joints, and often when the mobile joints do not move properly our stable joints will become unstable to over compensate. This results in painful movement. The knee is a prime example…it is a stable joint with two very mobile joints (the ankle and hip) at either end of it. Something as simple as an ankle sprain can cause altered body mechanics thatcausepain in theknee, even though theankleis thesourceof the problem.2.) Once you have diagnosed the source of the problem, go back to the basics to fix it. No one ever taught a baby how to sit up, roll over, crawl, or stand up…they started by laying on their backs and moving their limbs and eventually movement progressed as they got stronger. This is exactly what you should be doing to correct an altered movement pattern. Greg Rose created a simple tool called the 4 x 4 Matrix that includes the 4 basic body positions:1) Non-weight bearing (laying on your back or stomach)2.) Quadruped (face down on hands and knees)3.) Kneeling (full kneeling on both knees, or half kneeling on one leg)4.) StandingThese body positions are then utilized with the 4 different types of resistance:1.) Pattern assisted without resistance2.) No resistance3.) Pattern assisted with resistance4.) Full resistanceStarting with the easiest combination (1 x 1), the athlete learns the correct movement patterns and can build up from there. Greg suggests performing exercises in progressing body positions (1-4) with pattern assistance and no resistance (1-2) prior to moving onto progressing body positions (1-4) with pattern assisted resistance and full resistance (3-4). Greg has a full catalog of exercises on his TPI website:http://www.mytpi.com/exercisesOnce movement patterns that cause pain are addressed and corrected, the athlete can be re-assessed with the Functional Movement Screen and begin their training. Keep in mind that mobility issues always have to be addressed first before any stability issues can be fixed… we have to learn to crawl before we can walk, right?!?!For you athletes experiencing difficulty or pain, go back to the basics and work your way up. For you trainers and coaches, think outside the box and consider that your athlete’s knee pain might be caused by something other than their knee!! Put them through a movement screen as see where the problem is initiated from. I strongly recommend you check out Gray Cook’s websites:http://graycook.com/andhttp://www.functionalmovement.com/, as well as the Selective Functional Movement Assessment site:http://www.sfma.com/site/“First move well, then move often”~ Gray Cook-Erin